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The Art and Science of Handwashing

The Art and Science of Handwashing. Handwashing. 80% of common infections spread by hands Most effective way of preventing the spread of respiratory tract infections. Handwashing. 1822 - Labarraque – French pharmacist chloride solutions published paper in 1825

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The Art and Science of Handwashing

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  1. The Art and Science of Handwashing

  2. Handwashing • 80% of common infections spread by hands • Most effective way of preventing the spread of respiratory tract infections

  3. Handwashing • 1822 - Labarraque – French pharmacist • chloride solutions • published paper in 1825 • 1843 - Oliver Wendell Holmes • decrease in puerperal fever • 1846 - Ignaz Semmelweis • chlorine/nail brush • reduced deaths in obstetric wards • 20% 1%

  4. Improved Patient Outcomes Associated with Proper Hand Hygiene Ignaz Philipp Semmelweis (1818-65) Chlorinated lime hand antisepsis

  5. Puerperal fever • 19th century physicians • miasmas – bad air • Semmelweis • incontrovertible proof • refused to publish logic behind his theory • physician practice did not change • Joseph Lister • 20 years later • published in Lancet

  6. Handwashing • 1975, 1985 • CDC • Handwashing guidelines • 1988, 1995 • APIC • First to recommend alcohol based hand rubs • 1995,1996 • HICPAC • Antimicrobial soap/alcohol based agents • 2002 • HICPAC/SHEA/APIC/IDSA • Guidelines for Hand Hygiene in Health-Care

  7. Health-Care Associated Infections • USA • 2 million infections/year • 90,000 deaths • $ 4.5 billion / year • 1/3 preventable

  8. Resident Flora S. epidermidis / Micrococci / Diphtheroids Survive and multiply on skin Throughout skin layers Cultured repeatedly Low virulence Fingernails / crevices / hair follicles / sebaceous glands Not easily removed by scrubbing

  9. Transient Flora • E. coli, Klebsiella, Streptococci, Pseudomonas +/- S. aureus • Usually survive less than 24 hours • Do not multiply • Can be easily removed by handwashing

  10. How easy is it to transmit germs? • . • 103 – 105 bacteria to hands Touching patient shoulder Measuring blood pressure • Duckro AN et al. Arch Int Med 2005;165(3):302-7.

  11. Rings: • Trick et al, • CID 2003:36 • 10 fold higher median skin organism count • stepwise increase with number of rings worn

  12. Gloves: • 1) reduce transmission from patient to HCW • 2) prevent transmission of HCW flora to patient • 3) reduce transient contamination of HCW hands

  13. Impact of Hand Hygiene on Hospital Infections • Year Author Setting Impact on Infection Rates • 1977 Casewell adult ICU Klebsiella decreased • 1982 Maki adult ICU decreased • 1984 Massanari adult ICU decreased • 1990 Simmons adult ICU no effect • 1992 Doebbeling adult ICU decreased • 1994 Webster NICU MRSA eliminated • 1995 Zafar nursery MRSA eliminated • 1999 Pittet hospital MRSA decreased Source: Pittet D: Emerg Infect Dis 2001;7:234-240

  14. General hospital hand hygiene campaign Pittet, Lancet 2000

  15. Post-surgical acute care unit hand hygiene program Swoboda Crit Care Med; 2004:32:358

  16. Handwashing ComplianceIntensive Care Units Albert RK, Condie F. NEJM 1981;304(24):1465-6

  17. Lack of knowledge • Nursing students at some schools in Ontario: • no classroom training in infection prevention • SARS outbreak: • fewer than 60% of quarantined HCWs accurately identified why they were being quarantined

  18. How Dirty Are Things? LocationContamination (%) Playground 44 Bus Rails 35 Public Restrooms 25 Pens (shared) 16 Vending Machines 14 Public phones* 13 *home phones more contaminated University of Arizona study: Tucson Chicago San Francisco Tampa

  19. How easy is it to transmit germs? • 10 million E. coli 0157.H7 Patting contaminated ground beef • Wachtel MR et al. J Food Prot 2003;66(7):1176-83. • 103 – 105 bacteria to hands Touching patient shoulder Measuring blood pressure • Hayden MK et al. ICCAC 2001, abstract K-1334

  20. American Society for MicrobiologySurvey and Observational Study *After using public washroom NOTE:2003 Post SARS @ Toronto Airport – 96% actually washed

  21. Travellers • Percent who did NOT wash hands • JFK NYC – 29% • San Francisco – 26% • Chicago – 26% • Miami – 26% • Dallas Forth Worth -19% • Toronto – 4%

  22. School • 22 million school days lost annually to common cold (CDC 1996) • Am J Infect Control 2000 school with handwashing policy 2.42 days missed/student/year school not using proper hand hygiene 3.02 days missed/student/year

  23. Hand hygiene products • Regular soap  • Antibacterial x • Antiseptic  • Alcohol based  

  24. Hand hygiene products *triclosan, hexachlorophene, chlorhexidine gluconate Adapted from CID 1999;29:1287-94

  25. Antibacterial soaps Not needed in the community Not needed routinely in hospital Promote antibacterial resistance

  26. Antibacterial soaps Levy S S. aureus resistance to triclosan Schweizer et al AAC. 2001,45:428-432 exposure of P. aeruginosa to Triclosan • MIC to tetracycline, erythromycin 500X • MIC to ciprofloxacin 94X

  27. Triclosan: mechanism of action • Triclosan: Inhibits fatty acid synthesis (fab I gene) Target = enoyl reductase E. coli mutants easily selected with exposure S. pneumoniae, Enterococcus, lack fab I and are not susceptible Yazhankhah SP, et al. Microb Drug Resist 2006;12(2):83-90.

  28. Triclosan and antibiotic resistance • Resistance to triclosan: Mutation in fab I gene • fab I potential site for development of new antibiotics Activation / upregulation of efflux pumps • Multi-drug efflux = cross resistance Other resistance mechanisms not well understood Co-resistance to other antibiotics Thorrold CA, et al.Int J Food Microbiol 2007;113(3):315-20. Seaman PF, et al. J Antimicrob Chemother 2007;59(1):43-50.

  29. Akimitsu et al. • Antimicrob Agents Chemother 1999;43:3042-3 Methicillin Resistant S. aureus (MRSA): Link: antimicrobial soap and community acquired MRSA

  30. Antibacterial Household Products: Cause for ConcernStuart B. LevyEmerging Infectious Diseases, 2001;7(3):512-515 • Antimicrobial Resistance • Allergy Link

  31. Cause for Concern • Allergy Link • Too much hygiene and increased allergy • children on farms < allergies than children in cities Braun-Fahrlander. Clin Exp Allergy 1999;29:28-34 • Excessive hygiene may interfere with immune system • maturation of T helper cells • eliminate stimulation from commensal microflora • immune system not confronted with enough antigens • Folkerts et al. Immunol Today 2000;21:118-20

  32. Antibacterial products • > 700 different products • toothbrushes • plastic containers/chopsticks • sheets, towels, beds • window cleaner • No demonstrated health benefit in the household

  33. BacteriaGood or Bad Germs? 60% of earth biomass 2-3 billion microbial species < 0.5% have been identified Preceded plants / animals > 3 billion years Essential to life Both internal / external environments

  34. Antibacterial soaps Not needed in the community Not needed routinely in hospital No enhanced activity against viruses, fungi Promote antibacterial resistance

  35. Antiseptic soaps Not needed in the community for general hand hygiene Have a role in hospital setting May promote antibacterial resistance

  36. Alcohol Based Waterless Agents Advantages - no water required - fast to use Voss, Widmer. Infect Control Hosp Epidemiol 1997 - less drying time - less skin shedding Meers, Yeo. J Hyg 1978 - broad spectrum efficacy kill bacteria (fungi, viruses - do not promote resistance

  37. Alcohol Based Waterless Agents Disadvantages: • not effective in presence of organic material • will kill resident flora SHOULD NOT REPLACE SOAP AND WATER

  38. When to Wash Hands Before eating or preparing food After handling shared objects such as toys After wiping your nose or helping a child wipe his / her nose After using the toilet or helping a child use the toilet Before and after diapering

  39. Handwashing • Not long enough • average 9.5 seconds • need 15-20 seconds

  40. How to Wash Hands Use soap and water (water alone does not get rid of germs) Rub hands together for 20 seconds Sing Twinkle, Twinkle Little Star Song Rinse for 10 seconds Dry with a towel

  41. Hand Drying Removes 42% more germs than washing alone Use towels and avoid sharing towels Hot air dryers promote bacterial growth because hands are left warm and moist

  42. Does Handwashing Work? • Ryan M. Health Naval Research Center, San Diego Recruits ordered to wash hands at least 5 times /day  45% reduction in respiratory illness • Ryan MA et al. Am J Prev Med 2001;21(2):79-83 • Lee M. Canadian Journal of Infection, Toronto Nurses - at least 7 handwashing episodes/day  Decreased number of enteric / respiratory infections Lee MB. Can J Infect Control 2000;19:89-91

  43. Effect of Antibacterial Home Cleaning and Handwashing Products on Infectious DiseasesLarson et al Annals of Internal Medicine 2004 • Randomized double blind clinical trial 238 inner city homes with at least 1 preschool aged child - NY • Conclusion • Antibacterial products did not reduce the risk for symptoms of viral infectious diseases in households of healthy people • fever/sore throat/runny nose/vomiting/diarrhea

  44. The Effect of Hand Hygiene on Illness Rate Among Students in University Residence HallsAJIC 2003;31:364-70 • College dorms randomized : • Alcohol hand rubs in various locations vs. not. • Alcohol hand rub groups: • 14.8% -39.9% reduction in respiratory illness symptoms • 43% fewer sick days

  45. Effect of Handwashing on Child Health: A Randomised Controlled Trial • Squatter settlements in Karachi 50% reduction in pneumonia 53% reduction in diarrhea 34% reduction in impetigo • No difference between plain soap and antibacterial soap Lancet 2005;366:225-233

  46. www.dobugsneeddrugs.org

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